Aims. To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures. Methods. Data was obtained from the Northern Ireland DDH database. All children who underwent an attempted closed reduction between 2011 and 2016 were identified. Children with a dislocated hip that failed Pavlik harness treatment were included in the study. Successful closed reduction was defined as a hip that reduced in theatre and remained reduced. Most recent imaging was assessed for the presence of AVN using the Kalamchi and MacEwen classification. Results. There were 644 dislocated hips in 543 patients initially treated in Pavlik harness. In all, 67 hips failed Pavlik harness treatment and proceeded to arthrogram (CR) under general anaesthetic at an average age of 180 days. The number of hips that were deemed reduced in theatre was 46 of the 67 (69%). A total of 11 hips re-dislocated and underwent open reduction, giving a true successful CR rate of 52%. For the total cohort of 67 hips that went to theatre for arthrogram and attempted CR, five (7%) developed clinically significant AVN at an average follow-up of four years and one month, while none of the 35 hips whose reduction was truly successful developed clinically significant AVN. Conclusion. The likelihood of a successful closed reduction of a dislocated hip in the Northern Ireland population, which has failed Pavlik harness treatment, is 52% with a clinically significant AVN rate of 7%. As such, we continue to advocate closed reduction under general anaesthetic for the hip that has failed Pavlik harness. Cite this article: Bone Jt Open 2021;2(8):594–598

Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same. An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached. Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles. The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed. We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist. A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA. Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency. The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip

Introduction: This study examined the cohort of patients selectively screened over a 5 year period with ultrasonography according to our risk factors (positive Ortolani or Barlow manoeuvre, breech presentation, first degree affected relative and talipes equinovarus) for developmental hip dysplasia (DDH). The aims were to evaluate the success of those managed in a Pavlik harness and identify predictive factors for those that failed treatment. Methods: 728 patients were selectively screened between 1999 and 2004. Of those, 128 patients (189 hips) were identified as having hip instability. Failure was defined as inability to achieve or maintain hip reduction in a Pavlik harness. A proforma was designed to document patients’ risk factors and ultrasound findings at time of initial dynamic ultrasound scan where the senior radiographer and treating consultant were present. Each hip was classified according to Graf type. Acetabular indices were recorded prior to discharge. Results: All 128 patients with hip instability were managed in a Pavlik harness. This was abandoned for surgical treatment in 9 patients (10 hips) giving a failure rate of 5.3 %. All those successfully managed had an acetabular index of less than 30 degrees at follow up (6 – 48 months). 7 hips in the series were classified as Graf type IV, of these, 6 went on to fail management in a Pavlik harness. 67% of those that failed were also breech presentation compared to 22% of those managed successfully. There were no complications associated with management in a Pavlik harness. Discussion: Our overall rate of selective screening is 14 per 1,000 with a subsequent treatment rate of 2.3 per 1,000, which is comparable with other centres. Our rate of failure for DDH in a Pavlik harness (5.3 %) is extremely encouraging. Graf type IV hips and breech presentation correlated with a high likelihood of treatment failure

Introduction: This study examined the cohort of patients selectively screened over a 5 year period with ultrasonography according to our risk factors (positive Ortolani or Barlow manoeuvre, breech presentation, first degree affected relative and talipes equinovarus) for developmental hip dysplasia (DDH). The aims were to evaluate the success of those managed in a Pavlik harness and identify predictive factors for those that failed treatment. Methods: 1181 patients were selectively screened between 1999 and 2004. Of those, 128 patients (189 hips) were identified as having hip instability. Failure was defined as inability to achieve or maintain hip reduction in a Pavlik harness. A proforma was designed to document patients’ risk factors and ultrasound findings at time of initial dynamic ultrasound scan where the senior radiographer and treating consultant were present. Each hip was classified according to Graf type. Acetabular indices were recorded prior to discharge. Results: All 128 patients with hip instability were managed in a Pavlik harness. This was abandoned for surgical treatment in 9 patients (10 hips) giving a failure rate of 5.3 % (0.17 per 1000 live births). All those successfully managed had an acetabular index of less than 30 degrees at follow up (6 – 48 months). 7 hips in the series were classified as Graf type IV, of these, 6 went on to fail management in a Pavlik harness. 67% of those that failed were also breech presentation compared to 22% of those managed successfully. There were no complications associated with management in a Pavlik harness. 16 patients born within our region presented after 12 weeks of age with DDH resulting in a late presentation rate of 0.3 per 1000 live births. Discussion: Our overall rate of selective screening is 14 per 1000 live births with a subsequent treatment rate of 2.3 per 1000 is comparable with other centres. Our rate of failure for DDH in a Pavlik harness 0.17 per 1000 live births is an improvement on any previously published results. Irreducible hips, Graf type IV hips and breech presentation correlated with a high likelihood of treatment failure

Aims:. To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH. Methods:. It was a retrospective review of prospectively collected data. Patient's notes/computerised records were reviewed. Radiological investigations were also reviewed. Microsoft excel used for descriptive stats. Results:. From 1998 to 2011, 975 patients (1322 hips) were treated with Pavlik harness. Of these, 188 (20%) were male and 787 (80%) were female patients. The Pavlik Harness was successful in 92% patients and failed in 8% (102) patients. These 102 patients underwent closed reduction under general anaesthesia. Of these, the closed reduction was successful in 33 (20%) patients and failed in 69(68%) patients who then underwent open reduction. Conclusion:. The Success of closed reduction in patients with failed Pavlik Harness is low. Closed reduction may not overcome intrinsic and extrinsic obstructing factors responsible for failure of Pavlik Harness. Level of evidence: IV

Aim: To assess whether use of the Pavlik harness for the management of developmental dysplasia of the hip (DDH) can safely be discontinued without weaning. Method: The study group comprised babies diagnosed with DDH at the Royal Liverpool Children’s hospital over a 10 year period, between January 1995 and August 2004. The decision to instigate treatment with a Pavlik harness was based upon the Graf grade. We used Graf IIB or worse as our treatment threshold for the use of the Pavlik harness. In our practice the harness was removed when the hips were ultrasonographically and clinically normal, without a period of weaning. Results: There were 368 hips (273 babies) for analysis, 178 cases of unilateral DDH (128 left hips and 50 right hips) and 95 bilateral cases. Mean age at diagnosis was 59 days (range 1 – 187 days) with twenty-six patients presenting late after the usual 120 day time limit. Treatment with the Pavlik harness was successful in normalising 323 hips (87.8%). The Pavlik harness was unsuccessful in reducing 45 dislocations (12.2%). Patients were followed-up for a mean of 4.1 ± 2.7 years with no deterioration of acetabular indices on plane radiographs, according to the Tonnis classification. There were 4 hips with possible grade I avascular necrosis. To date there have been no cases of late dysplasia. Conclusions: Although many units remove the harness after a period of gradual weaning, practice is varied. Since we did not encounter any negative outcome despite not weaning we conclude that that weaning is unnecessary

This study shows the efficacy of The Pavlik harness for the treatment of Development Dysplasia of Hip using ultrasonographic monitoring. Between March 1995 and February 2000 we treated 149 dysplastic hips in 117 babies. According to the Graf’s classification 90 were dysplastic type IIB, IIC,IID hips; 59 were dislocated Type IIIA, IIIB and IV hips. Babies were regularly monitored using ultrasound until the age of 26 weeks and radiographs there after for bony roof angle. The Pavlik harness was abandoned if there was persistent dislocation of hip at the end of 3 weeks of treatment. The average full time harness treatment was 12.2 ( range 6–20 ) weeks. The average follow up was 55 ( range 30–90 ) months. The harness failed to reduce 14 hips ( 9.5 % of total hips). These required arthrogram and closed or open reductions. Late presentation beyond 12 weeks and a higher grade on the Graf’s classification reduces the success rate of the pavlik harness treatment. Two cases continue to show a small femoral ossific nuclei at 30 months follow up. The hips treated successfully showed no significant difference in acetabular index from the normal values at follow up radiographs. We conclude that using our protocol, successful initial treatment of Developmental Dysplasia of Hip with the Pavlik harness appears to restore normal development of the hip. We continue to monitor patients by regular radiological surveillance up to 3 years in dysplastic hips and 5 years in unstable and dislocated hips

Aims: This study shows the efþcacy of The Pavlik harness for the treatment of Development Dysplasia of hip (DDH) using ultrasonographic monitoring. Methods: Between 1995–2000 we treated 149 dysplastic hips in 117 babies. According to the Grafñs classiþcation 90 were dysplastic type IIB, IIC, IID hips; 59 were dislocated Type IIIA, IIIB and IV hips. Babies were regularly monitored using ultrasound unto 26 weeks and radiographs up to 5 years in dislocated hips for bony roof angle. Results: The average full time harness treatment was 12.2 (range 6–20) weeks, average follow up was 55 (range 30–90) months. The harness failed to reduce 14 hips (9.5% of total hips). Two cases continue to show a small femoral ossiþc nuclei at 30 months follow up. The hips showed no signiþcant difference in acetabular index from the normal values at follow up radiographs. Conclusions: We conclude that using this protocol, successful initial treatment of DDH with the Pavlik harness appears to restore normal development of the hip

The ossific nucleus in Developmental Dysplasia of the Hip. A study of relative ossific nuceus size in hips treated in the Pavlik harness and its predictive value in treatment outcome. Purpose. To assess the value of measuring relative ossific nucleus (ON) size difference in Developmental Dysplasia of the hip (DDH) as a potential predictor of outcome of hips treated in the Pavlik Harness. Study Design. Prospective study of all unilateral cases (n=68) of DDH identified in Southampton by dynamic ultrasound and treated in a Pavlik harness studying changes in relative ON size and acetabular indices over a mean follow up period of 3.6 years. Results. All cases responding to the Pavlik harness showed a progressive correction of ON size difference. Initial ON size difference was not associated with any difference in acetabular index at the date of last follow-up. Ultrasound grading of dysplasia did not affect the rate of normalisation of ON size difference. Conclusion and clinical relevance. In patients responding to treatment of DDH in a Pavlik harness, ON size difference was not found to be a useful prognostic indicator of outcome

There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring. This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective. One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable. We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely

Introduction: The Pavlik harness is widely used in the management of developmental dysplasia of the hip and its efficacy in the treatment of instability and acetabular dysplasia is well established. There are some hips which although reducible consistently fail to stabilise in a harness irrespective of the age of application. We report three cases in which through altering the method of application of the harness, stability and subsequent normal development was achieved. Method: Three patients age one week, six weeks and twelve weeks failed to stabilise in a harness applied in the conventional fashion. By rerouting the posterior “abduction strap” in front of the anterior “flexion” strap and attaching it as usual distally we observed improved abduction and more restriction of movement such that the unstable hip was held reduced. Reduction was confirmed by anterior ultrasound. The harness was converted back to the conventional application at four weeks by which time all of the hips had stabilised clinically. It was retained for a further eight weeks. Results: Significant dysplasia was evident in all three hips at presentation ( alpha angles 32, 48 and 34). At average follow up of 23 months all hips were concentrically reduced with no significant persisting dysplasia nor evidence of avascular necrosis. Discussion: Early reduction and stabilisation of the femoral head in DDH is important if subsequent intervention is to be minimised and it has been suggested that the more rigid Von Rosen splint is more effective than the Pavlik in achieving this. Our early experience with this simple modification has been successful in treating three unstable hips which would otherwise have failed splintage in our hands. We recommend it as an option to consider in the unstable hip, in conjunction with anterior ultrasound to confirm that reduction has been achieved from the outset

Between June 1988 and December 1997, 332 babies with 546 dysplastic hips were treated in the Pavlik harness for primary Developmental Dysplasia (DDH) as a product of the Southampton selective screening program. Each was managed by a strict protocol including ultrasonic monitoring of treatment within the harness. The group was prospectively studied over a mean duration of 6. 5 years (SD=2. 7y) with 89. 1% follow-up. The Acetabular Index (AI) and Centre-Edge angle of Wiberg (CEA) were measured on annual radiographs to determine the natural history of hip development following treatment in the Pavilik harness. These were compared to published normal values. We observed a failed reduction rate of 15. 2% of all complete hip dislocations; these required alternative surgical treatment. The development of those hips of infants successfully treated in the harness showed no significant difference from the normal values of Acetabular Index for female left hips, after eighteen months of age. Of those dysplastic hips that were successfully reduced in the harness; 2. 4% exhibited persisting significant late dysplasia (CEA< 20°) and 0.2% demonstrated persistent severe late dysplasia (CEA< 15 °) All such cases could be identified at sixty months. Dysplasia was clinically deemed sufficient to merit innominate osteotomy in 0. 9% dysplastic hips treated. Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that using our protocol, successful initial treatment of DDH with the Pavlik harness appears to revert the natural history of hip development to that of the normal population. We recommend that regular radiographic surveillance up to 60 months of age constitutes safe and effective practice

The aim of this study was to determine the inter and intra observer reliability of ultrasound measurements in treated unstable neonatal hips and whether ultrasound measurements correlate with radiological outcome at 6 months. Sixty-four babies treated from birth with a Pavlik harness for neonatal hip instability were scanned at 2 and 6 weeks. The α and β angles of Graf, the combined (H) angle of Hosny and the femoral head coverage (FHC) were measured by 3 observers and inter-observer and intra-observer repeatability co-efficients calculated using 95% confidence limits. Hips were categorized as normal, abnormal or borderline for each parameter and Kappa values calculated. A stepwise linear regression analysis was performed to assess any relationship between ultrasound measurements at 2 or 6 weeks and outcome as determined by acetabular index at 6 months. Seven hundred and ninety two sets of measurements were made from 248 scans. The α angle had the smallest interobserver range (17°), the H angle range was 21°and the β angle 28°. Kappa values showed good agreement for FHC and β angle. The mean acetabular index of all hips at 6 months was 26° (sd 4.9). The acetabular index was 30° or greater in 24 hips (18 babies) despite prolonged splintage in 9 hips (6 babies). The FHC at 6 weeks was predictive of acetabular index at 6 months (regression coefficient −0.27, 95% CI −0.42 to −0.12, p< 0.001). We recommend the FHC as being reproducible, useful and predictive of outcome in neonatal hips treated for instability

Developmental dysplasia of the hip presents different presentations and its treatment depends on early detection. 2975 patients younger than 6-month-old with hip ultrasonographies were studied between March 1998 and March 2001. In 26 patients, 33 ultrosonographically pathologic hips were detected and treated. 81% of the treated hips (27 patients) returned to their normal position before the 3rd week, only 6 remained dislocated and underwent surgical resolution. Patients with dislocated hips required an average of 12 week to complete the treatment protocol. Hip instability and subluxed hips healed between the 6th and 8th weeks. Those patients who began their treatment at one month old (10 hips – 33%) obtained the best results. To conclude, we agree with others authors on the effectiveness of the ultrasonographic method for early diagnoses and its use along treatment.

Aims. The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care. Methods. A qualitative study with semi-structured interviews was conducted between September and December 2020. A purposive sample of parents of children aged younger than one year, who were treated for DDH with a Pavlik harness, were interviewed until data saturation was achieved. A total of 20 interviews with 22 parents were conducted. Interviews were audio recorded, transcribed verbatim, independently reviewed, and coded into categories and themes. Results. Interviews revealed four fundamental information topics that should be addressed in the different phases of the DDH healthcare trajectory: general information (screening phase), patient-specific information (diagnostic and treatment phase), practical information (treatment phase), and future perspectives (treatment and follow-up phase). To further optimize the information provision in DDH care, parents wished for more accessible and trustworthy general information prior to the first hospital visit to be better prepared for the diagnosis. Furthermore, parents wanted more personalized and visually supported information for a better understanding of the nature of the disease and the reason for treatment. Conclusion. This study offers novel insights to optimize the information provision in DDH care. The main finding is the shift in information need from general information in the screening phase to patient-specific information in the diagnostic and treatment phase of DDH. Parents prefer visually-supported information, provided in a timely fashion, and tailored to their child’s situation. These recommendations potentially decrease parental anxiety, insecurity, confusion, and increase parental empowerment and treatment adherence throughout the diagnostic and treatment phase of DDH. Cite this article: Bone Jt Open 2023;4(7):496–506

Aims. Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods. This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years’ mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results. Of 202 infants who completed the protocol, 181 (90%) had two and five years’ follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years’ follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion. The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years’ follow-up. Cite this article: Bone Joint J 2024;106-B(7):744–750

Aims

Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment.

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants. A retrospective study of infant hip dysplasia over the period of 1998–2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. 179 infants (4.8/1000) presented with hip dysplasia. 34 infants presented late (>3 months of age) and required closed or open reduction. 145 infants presented at <3 months of age, 14 of whom failed early pavlik harness treatment. A detailed cost analysis revealed:. 131 early presenters with successful management in a pavlik harness at a cost of £601/child. 34 late presenters who required surgery (36 hips, 19 closed/ 17 open reductions, 1 revision procedure) at a cost of £4352/child. 14 early presenters with failed management in a pavlik harness requiring more protracted surgery (18 hips, 4 closed/ 14 open reductions, 7 revision procedures) at a cost of £7052/ child. Late detection causes increased treatment complexity and a seven-fold increase in the short-term costs of treatment, compared to early detection and successful management in a pavlik harness. However improved strategies are needed for the 10% of early presenting infants who fail pavlik harness treatment and require the most complex and costly interventions

To evaluate the safety and efficacy of treating patients with Graf IIa developmental hip dysplasia. The management of the developmentally immature Graf Type IIa dysplastic hip is controversial. Some authors advocate early treatment with an abduction harness whilst others adopt watchful waiting. At our institution selective sonographic assessment for developmental dysplasia of the hip (DDH) was established in 1997 with prospective data collection. All infants diagnosed with Graf Type IIa hip(s) were treated with either a Pavlik harness or double nappies, with clinical and sonographic follow up until normalisation. Pelvic radiographs were routinely performed at 8 and 18 months follow up for assessment of residual dysplasia and/or complications of treatment. We evaluated the safety and efficacy of all treated patients between 2005 and 2013. Complete clinical and radiological follow up (mean 2.1 years, 0.7–6.5) was available for 103 of 118 infants. 69 were treated with a Pavlik harness and 49 with double nappies. The chosen treatment was successful in 110 hips with no documented complications, well developed ossific nuclei on follow up radiographs, and no further treatments undertaken. In the double nappy group 4 infants deteriorated sonographically so were changed to a Pavlik harness with subsequent normalisation and successful treatment. 3 patients required VDRO at age 18 months (17–20) and 1 patient required closed reduction and spica cast treatment at age 11 months. No further complications arose in this group. The 15 patients lost to follow up had successful initial treatment but failed to attend for radiographic review. Both Pavlik harness and double nappies are safe treatment modalities for Type IIa hip dysplasia. However, sonographic deterioration was observed in both groups with surgical intervention required in the minority, supporting the ongoing treatment of these immature hips